N.J. de Wit

SYSTEMATIC REVIEW: THE ROLE OF DIFFERENT TYPES OF FIBRE IN THE TREATMENT OF IRRITABLE BOWEL SYNDROME

Background : Both high‐fibre dietary advice and the prescription of fibre as a bulking agent are very common in primary and secondary care management of irritable bowel syndrome. Irritable bowel syndrome patients with constipation may have delayed intestinal transit. Therefore, fibres that accelerate intestinal transit may be beneficial in these patients. The uncertain benefits reported in several clinical studies, however, have led us to reappraise the value of fibre in irritable bowel syndrome management.

Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial

Objective To determine the effectiveness of increasing the dietary content of soluble fibre (psyllium) or insoluble fibre (bran) in patients with irritable bowel syndrome. Design Randomised controlled trial. Setting General practice. Participants 275 patients aged 18-65 years with irritable bowel syndrome. Interventions 12 weeks of treatment with 10 g psyllium (n=85), 10 g bran (n=97), or 10 g placebo (rice flour) (n=93). Main outcome measures The primary end point was adequate symptom relief during at least two weeks in the previous month, analysed after one, two, and three months of treatment to assess both short term and sustained effectiveness. Secondary end points included irritable bowel syndrome symptom severity score, severity of abdominal pain, and irritable bowel syndrome quality of life scale. Results The proportion of responders was significantly greater in the psyllium group than in the placebo group during the first month (57% v 35%; relative risk 1.60, 95% confidence interval 1.13 to 2.26) and the second month of treatment (59% v 41%; 1.44, 1.02 to 2.06). Bran was more effective than placebo during the third month of treatment only (57% v 32%; 1.70, 1.12 to 2.57), but this was not statistically significant in the worst case analysis (1.45, 0.97 to 2.16). After three months of treatment, symptom severity in the psyllium group was reduced by 90 points, compared with 49 points in the placebo group (P=0.03) and 58 points in the bran group (P=0.61 versus placebo). No differences were found with respect to quality of life. Fifty four (64%) of the patients allocated to psyllium, 54 (56%) in the bran group, and 56 (60%) in the placebo group completed the three month treatment period. Early dropout was most common in the bran group; the main reason was that the symptoms of irritable bowel syndrome worsened. Conclusions Psyllium offers benefits in patients with irritable bowel syndrome in primary care. Trial registration Clinical trials NCT00189033.

Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice – an evidence-based international guide

Evidence suggests that the gut microbiota play an important role in gastrointestinal problems.

Outcome measures in irritable bowel syndrome: Comparison of psychometric and methodological characteristics

OBJECTIVES:Although there is growing interest in irritable bowel syndrome (IBS) research, there is as yet no consensus regarding the preferred outcome measure. We aimed to evaluate and to compare the validity and appropriateness of available IBS outcome measures.METHODS:IBS symptom and IBS health-related quality of life (HRQOL) scales were identified through a literature search. In a panel evaluation, six reviewers independently rated the scales according to predetermined psychometric and methodological validation criteria.RESULTS:Five IBS symptom scales and five IBS HRQOL instruments were identified. Two of the symptom scales were rated as good. The Adequate Relief question scored best. This scale demonstrates responsiveness as well as face and construct validity, and its score was considered easy to interpret and appropriate for use. According to the reviewers, the IBS Severity Scoring System performed well with regard to psychometric capacities, but its practical utility was considered debatable. The properties of the other three symptom scales were suboptimal. The practical utility of the five IBS-specific HRQOL scales was considered poor. However, the reviewers agreed that, at present, the IBS Quality of Life measurement (Patrick et al.) is the best choice, because it has been the most extensively validated and shows appropriate psychometric quality.CONCLUSIONS:The Adequate Relief question is the measure of first choice when assessing global symptomatology as an outcome in IBS studies. For a more detailed IBS symptom assessment, the IBS Severity Scoring System is preferable. Finally, the IBS Quality of Life measurement scale can be used to establish changes in health-related quality of life.

Disease burden of post-infectious irritable bowel syndrome in The Netherlands.

Post-infectious irritable bowel syndrome (PI-IBS) has been established as a sequel of infectious intestinal disease (IID). The aim of this study was to estimate the burden of PI-IBS caused by the pathogens Campylobacter, Salmonella and Shigella, and to compare this with other outcomes associated with these pathogens. The attributable risk of PI-IBS due to bacterial pathogens was calculated and linked to national data on gastroenteritis incidence and measures for severity and duration of illness in order to estimate the burden of PI-IBS. One year post-infection, IBS developed in 9% of patients with bacterial IID. The burden of PI-IBS adds over 2300 disability adjusted life years to the total annual disease burden for the selected pathogens. PI-IBS is a frequent sequel of IID, resulting in a considerable disease burden compared to other outcomes. If this relationship is not considered, this will result in an underestimation of the disease burden of IID.

What makes the dyspeptic patient feel ill? A cross sectional survey of functional health status, Helicobacter pylori infection, and psychological distress in dyspeptic patients in general practice

BACKGROUND Dyspepsia is prevalent in about 30% of the general population in Europe, but only 25% of people with complaints consult their general practitioner. AIMS To study the relation between the severity of dyspeptic complaints and the health status of patients presenting to the general practitioner; and the relation with patient characteristics, Helicobacter pyloriinfection, and psychological distress. METHODS A cross sectional, general practice based survey of 360 unselected primary care dyspeptic patients from 92 general practices in The Netherlands was conducted. Symptom severity was measured using a validated symptom score,H pylori using a whole blood test, and psychological distress using the GHQ-12 test. Functional health status was assessed using the COOP/Wonca charts. RESULTS Symptoms lasting more than three months and presence of relevant psychological distress were both associated with higher levels of dyspepsia.H pylori infection, frequency of symptoms, and age had no influence on dyspepsia severity. Severity of dyspepsia and psychological distress, but not H pyloriinfection or duration of symptoms, affected health status univariately. Dyspepsia correlated with general health, daily activities, and social activities. In logistic modelling, health status was far better predicted by psychological distress than by dyspepsia severity. CONCLUSION The relation between dyspeptic symptom severity and health status is limited.H pylori infection relates neither to functional health status, nor to intensity of dyspepsia. Psychological distress is a major determinant of impaired health of dyspeptic patients in general practice and may be the clue to improvement of health status in many dyspeptic patients.

The management of common gastrointestinal disorders in general practice A survey by the European Society for Primary Care Gastroenterology (ESPCG) in six European countries.

BACKGROUND Gastrointestinal (GI) disorders account for 10% of all consultations in primary care. Little is known about the management of GI disorders by general practitioners (GP) across different European countries. AIM AND METHODS We undertook a postal survey of randomly selected samples of GPs in six European countries (UK, Holland, Spain, Greece, Poland, Czech Republic) to determine patterns of diagnosis, management and service use in GI disorders. RESULTS We received 939 responses, response rate 32%. Over 80% of GPs were aware of at least three national guidelines for gastrointestinal disease. The availability of open access endoscopy ranged from 28% (Poland) to over 80% (Holland, Czech and UK). For uninvestigated dyspepsia the preferred first line management was proton pump inhibitor therapy (33-82%), Helicobacter pylori test and treat (19-47%), early endoscopy (5-32%), specialist referral (2-21%). Regarding irritable bowel syndrome, 23% of respondents were familiar with one or more diagnostic criteria, but between 7% (Netherlands) and 32% (Poland) would ask for a specialist opinion before making the diagnosis. CONCLUSION The wide variation between GPs both between and within countries partly reflects variations in health care systems but also differing levels of knowledge and awareness, factors which are relevant to educational and research policy.

Reflux symptoms in general practice: diagnostic evaluation of the Carlsson-Dent gastro-oesophageal reflux disease questionnaire

Background : Amongst primary care patients with dyspeptic symptoms, those with reflux‐like symptoms or gastro‐oesophageal reflux disease are expected to benefit most from empirical proton pump inhibitor therapy. Recognition of this patient group, however, is difficult. The Carlsson–Dent gastro‐oesophageal reflux disease questionnaire was developed to justify the selection of primary care patients for empirical proton pump inhibitor treatment.

Diagnostic value of the proton pump inhibitor test for gastro-oesophageal reflux disease in primary care.

To assess the diagnostic accuracy of the proton pump inhibitor test in a primary care population as well as its additional value over reflux history, using the symptom association probability outcome during 24‐h oesophageal pH recording as reference test for gastro‐oesophageal reflux disease.

Analytical performance, agreement and user-friendliness of five C-reactive protein point-of-care tests

Abstract Background. Point-of-care (POC) C-reactive protein (CRP) testing is increasingly used in primary care to assist general practitioners (GPs) in the diagnostic workup for various complaints. The present study compares analytical performance, agreement and user-friendliness of five of these POC CRP tests. Methods. The following five POC CRP tests were evaluated: Afinion and NycoCard Reader II (both Alere), Eurolyser Smart 700/340 (Eurolyser), QuikRead go and QuikRead 101 (both Orion Diagnostica). Results were compared with those of a standard immunoturbidimetric method performed on a routine analyzer (Olympus AU 2700, Beckman Coulter). Analytical performance and agreement with the laboratory standard for the five different POC tests were analyzed. Subsequently, user-friendliness of the POC tests was assessed. Results. Within-day CVs varied from 2.6% (QuikRead go) to 19.4% (Eurolyser Smart 700/340) for low CRP values (< 20 mg/L), and 1.1% (QuikRead go) to 17.5% (Eurolyser Smart 700/340) for high values (> 100 mg/L). Between-day CVs varied from 4.6% (Afinion) to 30.5% (Eurolyser Smart 700/340) for low values and 4.0% (QuikRead go) to 18.0% (Eurolyser Smart 700/340) for high values. With high CRP values (> 100 mg/L) agreement with the laboratory standard systematically decreased for all POC tests. Regarding user-friendliness Afinion and Eurolyser Smart 700/340 were judged easiest to operate. Conclusions. Analytical performance, agreement, and user-friendliness of the POC CRP tests varied considerably, yet overall four devices showed adequate analytical performance and agreement.